The Obligatory Amy Winehouse Post

It’s now been over a week since singer Amy Winehouse died, and there’s been a million stories.  We still don’t know what the actual cause of death was.  Some say it was likely an overdose, others say it was alcohol withdrawals that killed her – or maybe it wasn’t even drug related, we simply don’t know.  Either way, the added element in this story that makes her death stand out is that Winehouse’s biggest hit song titled “Rehab” contained an extremely catchy chorus with the lyrics stating:

They tried to make me go to rehab, I said, “No, no, no”

Yes, I’ve been black but when I come back you’ll know, know, know

I ain’t got the time and if my daddy thinks I’m fine

He’s tried to make me go to rehab, I won’t go, go, go

It’s easy to say “there ya go – she didn’t want to get help, she refused rehab, and now she’s dead”, but that’s a rather naive and uninformed comment.  Winehouse had in fact been to rehab several times (estimates range from 4-8), and it is well known that she just left another rehab mere weeks before her death.

The true significance of Amy’s hit song is that rather than showing us that she didn’t want help, or didn’t want to change, or that she was “in denial” – it really showed us that she had developed resistance or an aversion to being controlled, confronted, and told how to live.

They tried to make me go to rehab

He’s tried to make me go to rehab

See what happens when you stop focusing on the “no no no”?  You’re left with a song about coercion.  “Rehab” isn’t an anti-rehab or anti-change song – it’s anti-coercion anthem.

Winehouse’s resistant reaction isn’t surprising, and it is in fact the number one challenge that comes up with conventional methods of helping people with substance use problems.  Moreover, it’s almost entirely created by the people who try to help them.  Counselors, psychiatrists, various authority figures, and loved ones all approach addicts with the assumption that they must not realize they have a problem (that they’re in denial).  They come to the conversation (or should I say lecture?) ready to confront, lay down the law, and impose their judgment.  Most people don’t like to be controlled, so when someone pushes at them (“you’re an alcoholic and you can never drink again, you better do what I say”), the addict pushes back (“screw you, I’ll do whatever I want”).  The adversarial relationship escalates, and nothing gets accomplished.  Rather than backing down, the next step at that point is to try to literally force them into submission (inducing a ‘rock bottom’ point).  The game expands beyond the psychological realm into the material realm – people withdraw material support, sabotage careers by telling the addict’s employers about their habits, they sabotage relationships (a spouse tattling to parents, or parents tattling to a spouse), they take away children, and they even call the police on the addict so she’ll be caught and arrested with drugs.  Don’t get me wrong, any of these measures may be a rational course of action in a given set of circumstances, but the overall strategy of confrontation and control in and of itself is not effective in helping someone to change – it only increases resistance to a level which necessitates a battle – often of epic proportions.

Not surprisingly, this controlling approach to helping people make sensible choices hasn’t worked out well (mostly because it demands that they submit to someone else’s wishes, rather than choose for themselves).  AA, which abides by the control model philosophy, loses 90-95% of new members within a year of joining – and treatment programs for addiction almost never beat natural rates of recovery.  What’s more, addiction seems to escalate after people are coerced into treatment programs and 12-step meetings – with one famous study (Brandsma) showing that alcoholics randomly assigned to treatment programs display 5 times as much binge drinking post-treatment as those who were randomly assigned to receive no treatment!  Rehab doesn’t work – and there is now mounting evidence that the controlling approach so often recommended is to blame (we’ll get to that later).

Taking Control Of Addicts

Enter Dr Keith Ablow, whose comments evoke massive cringes out of me every time I see him on Fox News (he’s their resident psychiatric contributor).  He wrote a column about Amy Winehouse in which he really misses the point.  However, the column serves as a good example of the typical attitude of addiction treatment providers:

The sudden death of 27-year-old recording artist Amy Winehouse, in circumstances related to her abuse of alcohol and illicit substances, proves not only that alcoholism and drug dependence can be lethal, but that strategies to control it sometimes must be extremely aggressive and unrelenting—even if that means, for example, having the person formally declared incompetent, hospitalizing that person against his or her will a dozen times on a locked psychiatric unit or literally watching that person swallow Antabuse (which causes extreme, emergent physical distress when combined with alcohol) every single day.

Wrong, wrong, wrong, Keith.  When resistance is the problem, you don’t come back at it with more resistance.  What he’s suggesting here is that we use psychiatric commitment as punishment, that we strike fear into addicts as incentive to stop.  And when he says “against his or her will” nothing is unclear – he wants us to literally use force to stop people from using substances.  But wait, it gets worse, here are some of Ablow’s greatest hit quotes from this column:

I have told many patients (including some referred as a condition of probation after drug driving arrests) that, because of their past behavior while intoxicated, I will require them to take random drug tests and will automatically commit them to locked psychiatric units if I learn that they have begun drinking or using drugs again (or if they refuse the tests).

One Flew Over The Cuckoo’s Nest?

If an alcoholic takes Antabuse in the morning, drinking that day or night (or the next day) is likely to cause severe symptoms, including skyrocketing blood pressure, nausea and even death. Not infrequently, I insist that a family member (or that I) actually observe the alcoholic take his or her Antabuse (crushed and dissolved in water, to prevent spitting the medicine out later or throwing it up).

DEATH?!?!?  Wonderful.

On occasion, I have electronic bracelets applied to patients’ ankles that automatically monitor their perspiration for any alcohol content.

I coach families on how to go to court and get medical or legal guardianship (or both) over those alcoholics who simply won’t stop drinking

I have had several patients actually relocate for extended periods of time (sometimes years) to the area in which my office is located in order to give me the proximity, access and authority to keep them from their self-destructive addiction.

What would’ve helped Amy Winehouse?

Well, no one can say what would’ve helped her for sure (because of course you’re not dealing with a pathogen, you’re dealing with a person who freely makes their own choices), but I feel confident in saying that everything Dr Keith Ablow laid out above does exactly the wrong thing – it ups the ante on control and confrontation, and increases resistance – thus would not have helped Amy Winehouse.

Nevertheless, we know how to get around resistance.  The technique of Motivational Interviewing (MI), specifically teaches practitioners to use a non-confrontational approach with addicts.  It rejects the notion of denial and the tendency to coercion – and thus is at odds with THE ENTIRE TREATMENT INDUSTRY.  However, when added to nearly any existing treatment approach, MI effectively doubles success rates (and even with that doubling effect, treatment success rates are still dismal).  So, to some degree, treatment providers have used the technique, because it is almost the only thing in the mainstream of addiction treatment which has been proven to have any good effect, and by paying lip service to it, they can claim to be using “evidence based treatments.”  Never deterred from their original vision of addiction though – these people usually follow it up with a conventional approach which completely contradicts MI’s tenets. (see The Tragedy of MI)

Anyways, MI reduces resistance, and here’s why: it’s about talking to someone on an adult level, treating them as capable of making their own decisions, and respecting their opinions, desires, and values.  That’s the kind of conversation that would help facilitate some change in an Amy Winehouse or anyone else who predictably displays resistance in response to their helpers’ confrontational approach.  What’s more, the method has consistently outperformed controlling approaches in clinical trials – which tells me that the controlling approach is a bad idea.

While we didn’t formally MI with our students at the St Jude Retreats, we approached them with a similar spirit (now called The Freedom Model).  My life coaching training at NYU followed the same spirit as well.  And I take the same tact presently in the services I offer for helping people with substance use problems.

Rather than commanding people, and instituting controls over them, a mature approach is to engage them in rational thought about their habits.  This can be done through education and respectful discussion.  Then they’re free to make choices based on their own judgment – and that’s how a real choice is made.  The controlling approach doesn’t allow people to make their own choices – it simply starts a battle, robs the troubled person of the ability to choose, and imposes the helper’s choices.  Sometimes, the troubled person relents, and allows themselves to be controlled for a time (interventions are a perfect way to get this result), but in the long run, this person has never made their own choices about sobriety, thus they have no practice in making more successful choices, thus they eventually fall flat on their face and go back into addiction.

My Point?

Stop trying to control addicts.  It creates resistance and actually lowers their chances of solving their substance use problems.  Amy Winehouse’s hit song was a display of resistance which was most likely a reaction to encountering the Control Model approach.  What would’ve happened if instead of trying to control her, people treated her as competent and capable of change?  I think her chances for changing would’ve been better, and we wouldn’t be having this discussion now.  It’s amazingly sad that when controlling approaches fail to get good results again and again that Dr Keith Ablow and his ilk refuse to get the point, and instead double down on promoting further controlling measures.